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SAN JOAQUIN COUNTY -- ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209)468-3420 Fax:(209)468-3433 Web'.'WWW.Sjg0v.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name Page_j_of Facility Address: DItY• Inspection pat FA#: PR M Program Element: r Tank/Container Information Complete for all sites with cumulative aboveground,storage of petroleum.zt 1,320 gallons in tanks"and containers"". Complete one box for each tank or each cumulative container roduct type. Tank (2820) ❑ Containers (2821) -#of Containers: TA#: 1 S. Total Capacity: gallons Product Type: _JL (per tank or cumulative for containers by product type) Install Date: XTank (2820) ❑ Containers (2821) #of-Containers: TA#: 2 Total Capacity: ;Jo gallons Product Type: (per tank or cumulative for containers byproduct type) Install Date: . ❑ Tank-(2820)- xContainets (_2821) #of Containers: TA#: 3Product Type: o) Total Capacity; gallons (per tank or cumulative fof containers byproduct type) Install Date: _j _ ❑ Tank (2820) KContainers (2821) #of Containers: TA#: 4 Product Type: 6) Tota! Capacity: gall__�E - ons (per tank or cumulative for containers by product type) Install Data: ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: $ f. Product Type: Total Capacity: alto P Y gz ns (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 010 + gallons Total Capacity for Site: gallons Comments: IF I EHD In ector: ReviewedDate: Entered Date: By Initial: Q,,f— V13 l 8y Initial: f j *AW64 grou d storage tank means a nk that has the capacity to store 55 gallons c more of petroleum. C Altainer means a storage device designed to be moved when full. EHD 2rel 09/12/08 AST SURVEY FORM